THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) NOTIFICATION OF PARENTAL RESPONSIBILITY IN A DELINQUENCY CASE Pursuant to RSA 169-B:2-a Any parent or parents, guardian or other person responsible for the welfare of a juvenile alleged to be delinquent has the obligation to: 1. Personally attend and assure the attendance of the juvenile at all court hearings; 2. Personally attend and assure the attendance of the juvenile at all meetings with Health and Human Services and other collateral support service agencies occasioned by the action; 3. Fully participate in all services ordered by the Court including, but not limited to, substance abuse treatment, parenting classes, mediation, diversion and community service; 4. Pay a portion, or all, of any restitution of fines imposed by the Court or court approved diversion program fees, when the Court finds payment by the parent to be in the interest of justice and rehabilitation; and 5. Supervise the juvenile's compliance with all orders of the Court and conditions of release and probation including, but not limited to, curfew, school attendance and general behavior; 6. Pursuant to RSA 169-B:40 (DELINQUENCY), parents and other individuals chargeable by law for the juvenile's support and necessities may be liable for expenses incurred in the proceeding, including the costs of certain evaluations and placements and the cost of court-appointed counsel. RSA 186-C regarding children with disabilities grants children and their parents certain rights to services from school districts at public expense and to appeal school district decisions regarding services to be provided. Failure to supervise or otherwise accept responsibility as set out above may be treated as contempt of court, punishable by up to a $1,000.00 fine and 90 days imprisonment. It shall be a defense to any such charge of contempt that the parent, guardian or such other person or persons having custody of the juvenile made reasonable efforts to comply. Date Date Date Signature/Relationship to Juvenile Signature/Relationship to Juvenile Signature of Attorney I have reviewed this acknowledgment with the above person(s) and have determined he/she understands the parental responsibilities. So Ordered: Date Signature of Judge Printed Name of Judge NHJB-2355-DF (03/22/2012) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com